into a like number. In cases where the head is found very high up-for instance, when the membranes have either spontaneously ruptured or have been artificially broken, having held an undue quantity of liq. amniiwe have traced the sagittal suture pretty nearly parallel with the conjugate diameter. After a pause, during which the uterus is shrinking and contracting on the child, a pain or two moves the head, and the suture is then found in the transverse diameter, and under the influence of uterine contraction it is transferred into the oblique diameter-then one or other parietal bone is found to present, denoting the altered movement of the head on its own axis, and so with a partial movement of rotation, slightly shifting the presenting part to the posterior quarter of the parietal bone, the head emerges from the outlet. All this is done surely and correctly— there is the mechanism for it-the provision against mechanical error-and that error is avoided. It is a law-a rule of nature: and as long as the pelvis and the child's head are healthy, holding their mutual and just relation, so long, we believe, there is a security against that variety of vertexpresentation, which, in the infancy of obstetric knowledge, was thought to be the invariable one, and which still holds a questioned and doubtful existence in the classification of some of the authors of the present day. Amongst the irregularities in head-presentations, Dr. R. classes those in which the anterior fontanelle is behind one or other acetabulum, or, as he expresses it, the face towards either groin. He admits the occasional three-quarters turn described by Naegele, by which the face is directed backwards; but he thinks that this distinguished obstetric physician has overrated the frequency, as well of the presentation as of the mode of the head's passage, when it does occur.

We have already seen something of the conservative character of Dr. Ramsbotham, and we suspect that it peeps out here again. He has lost all ductility, and will not bend to any thing that looks like novelty. Thus Naegele's views are confined to one of the annotations, and he describes the diagonal positions with the face behind the groin as "tedious cases, with greater sufferings, and the time of duration more protracted than usual." We are not disposed to assent to this conclusion; for we have frequently witnessed the three-quarters turn completed, without any ap parent difficulty, without augmenting the suffering or protracting the labor. One of the great practical advantages resulting from a correct estimate of Naegele's views on the mechanism of these presentations is, the reliance it induces in the resources of Nature. There is no need of interference-no need of rectifying positions. Dr. R. counsels his readers not to meddle early in the labor where the face is forwards, and behind the groin-in the hope that Nature will complete the delivery. "Presuming, however, that, after a number of tolerably strong expulsive pains, no advance takes place in the situation of the head, it will then be proper to embrace the cranium between the three first fingers and the thumb of one or other hand, and to give the face an inclination to one or other ilium, according as its original direction was to the right or left groin." The same manœuvre is to be performed when the head enters with its long diameter in the conjugate diameter of the pelvis. We firmly believe this practice to be worse than useless. There is no doubt that apparent success has frequently followed its adoption; but the propitious result is due to natural causes, and

not to the artificial means. We think it very difficult, if not impossible, to command the necessary power by the hand alone to effect this rotation where only it could be needed in the first-named position, viz. where the head is firmly wedged in the cavity of the pelvis, requiring much time to overcome the resistance. But we think it better practice to wait patiently, as in the more usual vertex-presentation, and treat both class of cases exactly in the same way. With the exception of Dr. R.'s views on the mechanism of these vertex-presentations, we think the remainder of the work on practical midwifery is in general characterised by a sound discretion, and a practical familiarity with the subjects he treats of. In speaking of that variety of breech-presentation where the face and front of the child are directed anteriorly, he says, "I believe that in no instance, if the case were left entirely to Nature, provided the child and pelvis were of common size and form, would the face be expelled under the arch of the pubes." In this we fully concur, and we only want Dr. R. to extend the same amount of implicit faith in Nature's ways and means to the conduct of a head under like circumstances. We could have well dispensed with the unsightly drawing of an operation under this form of breech case, which almost spoils and counteracts the wholesome precept we have just quoted. "When the shoulders," says Dr. R., " are about to pass, it is our duty to take care that they are offering themselves in that position most favourable for their exit; and if they be not, to turn one under the arch of the pubes, and the other into the hollow of the sacrum." And the drawing sketches the hands of the operator in an active effort to secure this turn. We think these attempts to turn about the child, under the mistaken notion of helping its exit, have been a fruitful source of bad midwifery practice in the pelvic-presentations. Moreau's plates are beautiful representations of the mechanism of breech cases, and there is happily not one where the accoucheur's hands are at work.

In the added Section on the Diseases of the Puerperal State, we find Dr. Ramsbotham separating congestion of the uterus, or, as he terms it, vascular congestion, from hysteritis. The first is a necessary forerunner and companion of the last affection, but it may fall short of it, and is readily amenable to treatment. We recognise the distinction as practical. The congestion is venous, and generally, but in our experience not always, the lochia are suppressed or scanty. There is no rigor, and but little excitement of the circulation. The uterus is tumid and tender, and contraction causes much suffering. It may follow any labor, but a lingering or instrumental labor, or where the hand has been introduced, are apt to induce it. A frequent cause of it, in our experience, is a neglected state of the bowels, and it soon yields to a free purgation or a large enema. Dr. R. leeches, and gives a brisk purgative of calomel and other cathartics, and uses emollient injections. We have rarely found it necessary to leech; for, when the bowels are cleared, and hot narcotic fomentations applied to the vulva and hypogastrium, the venous circulation is relieved, the lochia flow, and the uterus diminishes in size and sensibility.

Dr. R. regards phlegmasia dolens as one of the most interesting diseases affecting the puerperal state. He thinks the left leg is more frequently attacked than the right; and this "may probably," he says, "in some inexplicable manner, be dependent on the different distribution of

the right and left spermatic vein." He thinks that those who have suffered profuse uterine hæmorrhage are frequent subjects of it. In accordance with the dissections of Dr. Robert Lee, and the author's late colleague Dr. David Davis, to whom he ascribes priority in the discovery, Dr. R. looks upon the venous system as that mainly involved in this affection; and very justly, in our minds, disclaims its near relationship with puerperal fever. It may come on in the course of puerperal fever, and be excited by a puerperal poison; but we think with our author, that there are important distinctions between them. In the treatment, Dr. R. advocates local depletion and mild aperients, for powerful cathartics are generally injurious; the limb is to be enveloped in new flannel, over which there is to be a covering of oil-silk. When the affection has lasted some days, and the pain still continues, advantage may be gained by leeching over the femoral or popliteal veins, and the use of the local vapour bath. And in the more chronic stage, frictions, with or without stimulant embrocations, and a properly adapted bandage are of essential service.

There is a useful chapter on Puerperal Mania, from which, however, we have not space to select any passages.

Dr. Ramsbotham has bestowed some pains on the chapter which treats of Puerperal Fever, and on this most perplexing and intricate disease Dr. R. has advanced somewhat novel views. It is true that he enters on the subject" with unfeigned diffidence," and "he hopes he may not be deemed presumptuous in stating," &c. &c. All this is very pretty, languishing, and lady-like, and would be very becoming in a man just past his teens, in his thesis for a degree. But when Dr. R. tells us that "his opinions are not grounded on a single series of cases, but that, having carefully watched its annual appearance in the eastern districts of London, they are deduced through the experience of a number of years, from cases occurring under many varieties of circumstances, and in all ranks of society from the most distressed pauper to persons in comfort and affluence"we have a right to expect something which bears the mark of maturity, unclogged with trifling apologies.

Dr. R. does not like the term puerperal fever-he thinks it vague and undefined, and that it has been a snare to practitioners, and has caused fatal mistakes. It appears to him that the term has been applied to four very different diseases, which he describes under the titles of Peritonitis, Acute Tympanitis, False Peritonitis, and Typhus.

Puerperal Peritonitis appears under two forms, sporadic and contagious or epidemic, the latter of which may be communicated through the intervention of a third person-the nurse or medical attendant. Both forms are described together. The attack may be acute or insidious, and the epidemic form partakes largely of the nature of erysipelas. Among the exciting causes, the peculiar states of atmosphere are, we are sure, most properly insisted on; but Dr. R. speaks most obscurely of the immediate cause, mentioning a poisoned circulation as the opinion of others, but "with more truth and justice (he says) Locock and Ingleby regard the primary impression as made on the nervous system."

The symptoms which attend an acute case of Puerperal Peritonitis are well and faithfully described-the acute agonising tenderness, with the posture it occasions-the permanently quick pulse-hurried respiration

short cough peculiar countenance-the frequent suppression of both lochia and milk-the tendency to metastasis-then the period of effusion, tympanitis, delirium, sinking, and death.

"When the disorder appears as an epidemic, though the chief symptoms are still the same, many are greatly aggravated. The pulse is much more rapid than in the sporadic variety; it frequently rises at once to 140 or 150 in the minute, and is at the same time very small and easily compressed; the fever assumes more of a low type even from the commencement, and runs its course with far greater rapidity; the prostration of strength is more complete; the skin is cooler, being seldom above the natural standard; the belly becomes more early swollen and tympanitic; the breath acquires a faint and earthy odour; hiccough often occurs, from the irritability of the diaphragm, consequent on the distension of the stomach and intestines; abscesses form occasionally, either among the muscles of the extremities, or within or around the joints; and Lee, Marshall Hall, Locock, Ferguson, and Rigby, mention that the eyes, particularly the left, are sometimes attacked with a rapidly destructive inflammation; but this I have myself never observed; probably because the disease is always more severe in hospital practice." P. 586.

The morbid appearances are said to be "in different cases very generally the same." Fetid gas in the abdominal cavity, the result of rapid decomposition of the body after death-the peritoneum and omentum injected, and in patches, thickened and opaque—a varying quantity of serum gravitating towards the pelvis-patches of lymph, more or less consistent, and sometimes exclusively coating the surface of the uterus, are the evidences of peritonitis. The uterus is generally contracted-its proper structure sometimes soft and dark in colour, with pus either in its veins or its structure. The ovaries frequently are more vascular, and coated on their surface with a thick lamina of lymph. Not unfrequently they are reduced to a pultaceous mass, of a larger bulk than usual, and occasionally they are even converted into abscesses.

Sterility sometimes follows an attack of puerperal peritonitis, which may well be expected when the lesions of the ovaries, tubes, &c., are considered. In the treatment, Dr. R. is an advocate for vigorous antiphlogistic measures. Bleeding, early in the disease and largely, taken in full stream, until syncope is produced, is the first and most efficacious measure. Dr. R. thinks that this measure falls into discredit, by those who are prejudiced against it, by the blood being withdrawn either in too small quantity, or at too late a period in the disease, when in fact the stage of exhaustion has set in. After bleeding, the next object should be to purge freely. Ten or twelve grains of calomel, followed by a dose of infusion of senna or jalap, repeated every three or four hours until stools are procured; and, if the draught is rejected, an enema, or a drop of croton oil, are the means selected by Dr. R. A second bleeding may be practised if the disease, having only been suspended, should return with violence in a few hours; or, should the symptoms be mitigated, 18 or 24 leeches may be applied over the abdomen, followed by fomentations or a warm well-made linseedmeal poultice, on which may sometimes be sprinkled some spirits of turpentine. Dr. R. does not like blistering the surface of the abdomen, but he sees no objection to applying blisters to the inside of the thighs. Calomel and opium, or Dover's powder, in the proportion of three grains of the first to a quarter or half-grain of opium, or an equivalent quantity of

Dover's powder, are to be given every two or three hours, until ptyalism is produced, or the abdominal tenderness disappears.

Dr. R. does not place much reliance on emetics, and restricts their administration to cases where vomiting ushers in the disease.

"If the lochia be suppressed, or possess a bad odour, which is almost always the case, the vagina may be syringed every four or five hours with warm water, or a weak solution of the chlorates.' The sparest diet ought of course to be allowed.

These active means apply only to the first stage of peritonitis. They must be changed, when the second stage or exhaustion sets in, for a stimulating and supporting plan. The disease throughout requires the most narrow watching on the part of the attendant physician.

"Every one must acknowledge that this subject is beset with great difficulties, both in description and practice; and these difficulties are increased by the fact that the various epidemics, whose histories we possess, have differed much from each other, being modified by the constitution of the atmosphere, and partaking much of the character of the then prevailing diseases. What Sydenham has designated the constitution of the year, has scarcely been taken into account in the treatment of these diseases; this, however, it is of the utmost importance to attend to; for we shall invariably find that, if the common fevers of the season bear depleting well, the same means will prove efficacious in arresting the puerperal diseases at the same time; while, on the other hand, if the typhoid type prevail, the lancet must be employed with a more sparing hand." P. 598.

The Acute Tympanitis of Dr. R. is nothing more than a variety of what Dr. Marshall Hall has described as "Intestinal Irritation," but he has selected the title on account of the prominent and peculiar symptom being a sudden and excessive tumefaction of the abdomen, accompanied by intense pain and depression.

The affection bears a strong resemblance to puerperal peritonitis. It begins two or three days after delivery with a severe rigor, succeeded by great heat and dryness of skin, both the rigor and heat of skin being more marked than in peritonitis. The pulse rises to 130 or 140, sometimes fluttering and tremulous, at others fuller and firmer than in peritonitis. The countenance becomes early changed, though not so anxious as in peritonitis.

"Most severe pain in the head is experienced, with intolerance of light and noise, uninterrupted wakefulness, and in many cases even delirium. Very early in the disease the abdomen swells inordinately and rapidly, becomes very tense and painful, and the transverse colon particularly can in many instances be distinctly traced: pressure aggravates the sufferings. The milk ceases to be secreted; the lochia are generally suppressed; there is great languor; an unwillingness to speak, or take nourishment; the patient lies on her back, with her legs drawn up, unsolicitous about herself, her infant, or her friends; the bowels are obstinately constipated.

"As the disease gains ground, the belly increases in size, pain, and tightness; the tongue becomes dry and brown; there is hiccough, or vomiting of offensive matter, muttering delirium, subsultus tendinum, and most of the symptoms that denote the last stage of fever; but if recovery is to be expected, the swelling and tenseness of the abdomen subside; the pain gradually goes off; the pulse becomes slower; the tongue moister; the skin cooler and softer; there is no vomiting; the intellects remain unimpaired; a desire is expressed for food; and the bowels act, together with the expulsion of a large quantity of flatus." P. 601.